We have received research funding from Takeda Pharmaceuticals; TAB has been
Torgerson JS, Hauptman J, Boldrin MN, Sjostrom L. Xenical in the prevention
on a speakers’ panel for and has received travel and accommodation expenses
of diabetes in obese subjects (XENDOS) study. Diabetes Care 2004;
Buchanan TA. (How) Can we prevent type 2 diabetes? Diabetes 2007;
Tuomilehto J, Lindstrom J, Eriksson JG, et al, for the Finnish Diabetes
Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med
The Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes
2001; 344: 1343–50.
Research (NAVIGATOR) Study Group. Eﬀ ect of nateglinide on the incidence of diabetes and cardiovascular events. N Engl J Med 2010;
Diabetes Prevention Program Research Group. Reduction in the incidence
of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393–403.
Zinman B, Harris SB, Neuman J, et al. Low-dose combination therapy with rosiglitazone and metformin to prevent type 2 diabetes mellitus
Chaisson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M, for the
(CANOE trial): a double-blind randomised controlled study. Lancet 2010;
STOP-NIDDM Research Group. Acarbose for prevention of type 2 diabetes
published online June 3. DOI:10.1016/S0140-6736(10)60490-4.
mellitus: the STOP-NIDDM randomised trial. Lancet 2002; 359: 2072–77.
10 Hazzard WR, Crockford PM, Buchanan KD, Vance JE, Chen R, Williams RH.
Buchanan TA, Xiang AH, Peters RK, et al. Preservation of pancreatic β-cell
A double antibody immunoassay for glucagon. Diabetes 1968;
function and prevention of type 2 diabetes by pharmacological treatment of
insulin resistance in high-risk Hispanic women. Diabetes 2002; 51: 2796–803.
11 Xiang A, Peters RK, Kjo SL, et al. Eﬀ ect of pioglitazone on pancreatic
DREAM Trial Investigators. Eﬀ ect of rosiglitazone on the frequency of
β-cell function and diabetes risk in Hispanic women with prior gestational
diabetes in patients with impaired glucose tolerance or impaired fasting
diabetes. Diabetes 2006; 55: 517–22.
glucose: randomised controlled trial. Lancet 2006; 368: 1096–105. Reducing the global burden of stroke: INTERSTROKE
Stroke is the second leading cause of death globally, countries. In The Lancet today, the INTERSTROKE
with more than 85% of deaths from stroke occurring in
investigators3 report the initial ﬁ ndings from their
developing countries.1,2 However, there has been little phase 1 case-control study of risk factors for stroke
See Articles page 112
research to identify the causes of stroke in low-income in 22 countries worldwide. The ﬁ ndings suggest that and middle-income countries. An understanding of ten key risk factors explain 90% of the population-the risk factors for stroke in these countries is crucial attributable risk for stroke, and that the risk factors to determine priorities and strategies for reversing the for stroke are similar to those previously identiﬁ ed rapidly rising rates of stroke mortality in developing for myocardial infarction in the related INTERHEART
The INTERSTROKE investigators classiﬁ ed participants
INTERSTROKE INTERHEART (all stroke; 3000 cases, (acute myocardial infarction;
into ﬁ ve regions: high-income countries, South America,
3000 controls)3* 15 152 cases, 14 820 controls)4†
southeast Asia (including China), India, and Africa. They
found that a self-reported history of hypertension or
acute blood pressure of higher than 160/90 mm Hg was
the most important risk factor for both ischaemic and
intracerebral haemorrhagic stroke. Whilst hypertension
is well established as the most important cause of stroke
in high-income countries, INTERSTROKE conﬁ rms
that it is also the most important risk factor for stroke
in developing countries.5 This ﬁ nding is particularly
relevant because it highlights the need for health
authorities in these regions to develop strategies to
screen the general population for high blood pressure
and, if necessary, oﬀ er aﬀ ordable treatment to reduce
the burden of stroke. It also provides an impetus to develop population-wide strategies to reduce the salt
Data are population-attributable risk (99% CI). *Adjusted for all stroke risk factors apart from ratio of apolipoproteins B to A1. †Adjusted for all myocardial infarction risk factors. ‡See original article for deﬁ nition of risk factor and
content in the diet of individuals in these countries.6
methods used to calculate population-attributable risk.
Smoking and abdominal obesity, as measured by
Table: Comparison of the population-attributable risk (99% CI) for common risk factors‡ in the
waist-to-hip ratio, were also identiﬁ ed as important risk
INTERSTROKE and INTERHEART studies
factors for stroke. Current smokers had a signiﬁ cantly
www.thelancet.comVol 376 July 10, 2010
higher risk of stroke in all regions, which reinforces the
Phase 1 of INTERSTROKE suggests that hypertension,
need to reduce the high smoking rates in countries such smoking, abdominal obesity, physical inactivity, and as China and India through tough anti-smoking policies diet are the most important modiﬁ able risk factors for if a growing stroke and coronary disease epidemic is to stroke. These important ﬁ ndings should help to inform be averted.7,8 The identiﬁ cation of waist-to-hip ratio (as stroke prevention strategies around the world and to opposed to body-mass index) as a risk factor for stroke reduce the global burden of stroke. is consistent with previous INTERHEART ﬁ ndings for myocardial infarction, and provides further evidence Jack V Tuthat this ratio might be a better measure of obesity to Institute for Clinical Evaluative Sciences, Sunnybrook Schulich Heart identify individuals at high risk for these disorders.9 A Centre, University of Toronto, Toronto, ON, Canada M4N 3M5
surprising ﬁ nding was the relatively low prevalence of I am supported by a Canada Research Chair in Health Services Research and a
cardiac causes of stroke (eg, atrial ﬁ brillation, rheumatic Career Investigator Award from the Heart and Stroke Foundation of Ontario. heart disease) in China and India compared with high-
I declare that I have no conﬂ icts of interest.
income countries, but this result may reﬂ ect, in part, 1
Johnston SC, Mendis S, Mathers CD. Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling.
lower rates of cardiac diagnostic testing. Lancet Neurol 2009; 8: 345–54.
Identifying the causes of stroke across many diverse 2 Strong K, Mathers C, Bonita R. Preventing stroke: saving lives around the
world. Lancet Neurol 2007; 6: 182–87.
regions with a standardised approach is a diﬃ
O’Donnell MJ, Xavier D, Liu L, et al, on behalf of the INTERSTROKE investigators. Risk factors for ischaemic and intracerebral haemorrhagic
research undertaking for many reasons. Although a large
stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet
international prospective cohort study might be the
2010; published online June 18. DOI:10.1016/S0140-6736(10)60834-3.
Yusuf S, Hawken S, Ôunpuu S, et al, on behalf of the INTERHEART Study
ideal, one would need to enrol a very large sample in view
Investigators. Eﬀ ect of potentially modiﬁ able risk factors associated with
of the relatively low incidence of stroke in the general
myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004; 364: 937–52.
population, and the challenges of the long follow-
Lawes CM, Bennett DA, Feigin VL, Rodgers A. Blood pressure and stroke:
up required would be considerable. A more eﬃ
an overview of published reviews. Stroke 2004; 35: 776–85.
Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease
approach is to use a matched case-control design, as in
prevention: health eﬀ ects and ﬁ nancial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007; 370: 2044–53.
INTERSTROKE, in which patients (or their proxies if they 7 Gu D, Kelly TN, Wu X, et al. Mortality attributable to smoking in China. could not communicate) in hospital with acute stroke
N Engl J Med 2009; 360: 150–59.
Jha P, Jacob B, Gajalakshmi V, et al, for the RGI-CGHR Investigators.
were interviewed and examined for possible risk factors,
A nationally representative case-control study of smoking and death in
and results compared with a control population matched
India. N Engl J Med 2008; 358: 1137–47.
Yusuf S, Hawken S, Ôunpuu S, et al, on behalf of the INTERHEART Study
for age and sex from the hospital or the community.10
Investigators. Obesity and the risk of myocardial infarction in 27 000
Such a design can yield useful information but selection
participants from 52 countries: a case-control study. Lancet 2005; 366: 1640–49.
or recall biases might occur in terms of the individuals (or 10 O’Donnell M, Xavier D, Diener C, et al. Rationale and design of
INTERSTROKE: a global case-control study of risk factors for stroke.
their proxies) who agree to take part as either cases or
Neuroepidemiology 2010; 35: 36–44.
controls.11,12 The INTERSTROKE investigators were aware 11 Tu JV, Willison DJ, Silver FL, et al, for the Investigators in the Registry of
the Canadian Stroke Network. Impracticability of informed consent in the
of these limitations and did sensitivity analyses that
Registry of the Canadian Stroke Network. N Engl J Med 2004;
showed that their ﬁ ndings were generally consistent
12 Schulz UG, Rothwell PM. Diﬀ erences in vascular risk factors between
between respondents (patient or proxies) and between
etiological subtypes of ischemic stroke: importance of population-based
studies. Stroke 2003; 34: 2050–59. Public health research funding: independence is important
The Diet and Health Research Industry Club (DRINC) is while enhancing the international competitiveness See Editorial page 69 a £10 million (US$16·7 million, €11·2 million), 5-year of the UK’s food industry and its ability to develop partnership between the UK’s Biotechnology and healthier foods. Research includes design of foods with Biological Sciences Research Council (BBSRC) and a enhanced nutritional properties and assessment of the consortium of leading companies.1 DRINC’s goal is to health beneﬁ ts of bioactive ingredients. The companies generate high-quality research into diet and health involved, which include Cadbury, Coca Cola, Nestlé,
www.thelancet.comVol 376 July 10, 2010
Cetirizine and pseudoephedrine retard, givenalone or in combination, in patients with seasonalallergic rhinitis*M. Grosclaude1, K. Mees2, M.E. Pinelli3, M. Lucas3, H. Van de Venne3Centre Claude Bernard, Guilherand-Granges, FranceHNO-Klinik Grosshadern, München, GermanyUCB S.A. Pharma Sector, Braine-l’Alleud, Belgium We compared the efficacy and safety of cetirizine (5 mg), pseudoephedrine
Empfehlungen der Deutschen Atemwegsliga zum Sport und körperlichem Training bei Patienten mit obstruktiven Atemwegserkrankungen H. Worth und A. Meyer (federführend), H. Folgering, D. Kirsten, J. Lecheler, H. Magnussen, K. Pleyer, S. Schmidt, M. Schmitz, K. Taube, R. Wettengel Korrespondenz: Prof. Dr. med. H. Worth Medizinische Klinik I, Klinikum Fürth Jakob-Henl